Complications and dangers in laparoscopic surgery and reasons for conversion to "open" (traditional) method of operating
I. M. Kapuwa, MD., M.A. Glushkov, MD., PhD.
(Department of Surgery. Central Clinical Hospital of the Russian Academy of Sciences, Moscow.)
Introduction
Over the recent years, a revolution has taken place in surgery requiring the retraining of tens of thousands of surgeons. This startling change has come about because of the rapid development of endovideosurgical (minimally invasive) technology and the expansion of its field of application. Many surgeons have rapidly adopted the laparoscopic technique in a wide range of operations. This has highlighted the principal advantages of the laparoscopic approach over “open” surgery, including reduced postoperative pain, shorter hospital stays and shorter periods of disability.
Naturally, the introduction of minimally invasive technology brings with it new challenges. The main one of them being the problem of safe and proper integration of laparoscopic operations in abdominal surgery.
Unfortunately, laparoscopic interventions are not without complications characteristic of "open surgery". Furthermore, there are specific complications. Complications, as well as complex anatomical situations encountered during laparoscopic surgery, can be the reason for transition/conversion to an open method of operating.
Material and methods
We are presenting the experience of complications and dangers encountered by Resident Surgeons when performing laparoscopic interventions carried out in our clinical hospital since 2013. During the period from September 2013 to April 2015, 1812 laparoscopic surgeries were performed, using the Karl Storz endoscopy.
Table 1. Laparoscopic interventions
Name of operation/
Diagnosis
|
Number of operations
|
Number of conversions
|
%
|
Laparoscopic cholecystectomy
|
1482
|
83
|
5.6
|
Laparoscopic appendectomy
|
27
|
7
|
25.9
|
Laparoscopic interventions in acute pancreatitis
|
30
|
4
|
13.3
|
Laparoscopic interventions in chronic pancreatitis
|
19
|
2
|
10.5
|
Viscerolisis- Adhesive disease of the abdominal cavity
|
26
|
4
|
15.4
|
Laparoscopic hernioplasty
|
124
|
2
|
1.6
|
Cyst resection- Kidney cysts
- Liver cysts
|
11
6
|
0
|
|
Adrenalectomy- Tumour of the suprarenal gland
|
4
|
2
|
50.0
|
Laparoscopic interventions in closed injury to the liver
|
5
|
0
|
|
Operations on the spleen
|
8
|
3
|
37.5
|
Laparoscopic interventions in dolichocolon
|
6
|
1
|
16.7
|
Re-laparoscopy
|
11
|
0
|
|
Diagnostic laparoscopy
|
53
|
8
|
15.1
|
Total
|
1812
|
116
|
Since the reasons for conversions differ for each pathology, we present below an analysis of the reasons for certain types of operations.
Conversion to laparotomy during laparoscopic cholecystectomy
Laparoscopic cholecystectomy has virtually replaced conventional open cholecystectomy as the gold standard for symptomatic cholelithiasis and inflammation of the gallbladder. The laparoscopic approach brings numerous advantages at the expense of higher complication rates, especially in training facilities; it has been adopted rapidly by most surgeons and embraced enthusiastically by the public.
In our hospital, there has been a reliably established decrease in the number of unsuccessful attempts at laparoscopic cholecystectomy due to the gaining of experience of each operating resident surgeon in particular and the operating room staff as a whole. The vast majority of failures accounted for surgery of a shrunken gallbladder and acute calculous cholecystitis.
Reasons for conversion during Laparoscopic cholecystectomy:
I. Inability to perform laparoscopic surgery due to morphological changes in organs and tissues.
1) a dense infiltrate in the gallbladder.
In the case of laparoscopic division of the infiltrate, there is a big chance of damage to organs involved in it. Sometimes these damages go unnoticed during the operation. This was the reason for the conversion of 24 observations, which accounted for 53.4% of total conversions for acute calculous cholecystitis and 10 (26.3%) in chronic calculous cholecystitis. Dense infiltrate in chronic calculous cholecystitis is also observed in a certain percentage, when the clinical symptom is consistent with chronic inflammation of the gallbladder, dense infiltration is usually diagnosed in routine patients intraoperatively. In nine (20%) patients with acute calculous cholecystitis, the reason for conversion was the combination of dense infiltrate with pericholecystic abscess.
2) Mirrizzi syndrome, internal biliary fistula.
We found Mirrizzi syndrome in 5.3% of all conversions in chronic calculous cholecystitis, in acute calculous cholecystitis, this pathology was not encountered.
3) Massive adhesions in the abdominal cavity.
Visible adhesion in the area of the gallbladder was the reason for conversion in 5 (13.2%) patients with chronic calculous cholecystitis. In 2 (5.3%) cases, we could not perform laparoscopic viscerolysis due to an earlier abdominal surgery. The adhesive process was more intense in the projection of abdominal incisions and areas of great damage to the peritoneum. Widespread adhesions were observed in patients previously operated on for intra-abdominal hemorrhage, peritonitis and after gynecological operations.
4) Evidence of sclerosis in the neck of the gallbladder with the inability to differentiate its structure.
In this case, we could not complete the operation laparoscopically in two (5.3%) cases with chronic calculous cholecystitis.
5) Cancer of the gallbladder was diagnosed intraoperatively in two cases, consisting of 4.4% of all conversions in acute calculous cholecystitis.
6) choledocholithiasis, including the impaction of large stones in the distal common bile duct, which was not possible to remove laparoscopically, caused the conversion of 4 (10.5%) patients with chronic calculous cholecystitis.
7) Gangrene of the gallbladder wall.
When there is gangrene of the gallbladder wall, it loses its strength, making it impossible for traction. This pathology was the cause of conversion in two (4.4%) cases with acute calculous cholecystitis due to inaccurate information of the preoperative ultrasound result.
8) cholecystogastric, cholecysto-duodenal, cystocolic fistula: in two cases (4.4%) the cause of the conversion during laparoscopic cholecystectomy was cholecystogastric fistula in acute calculous cholecystitis; in another - cholecysto-duodenal fistula in chronic calculous cholecystitis (2.6%).
II. Obscure anatomical relationships at the region of the neck of the gallbladder and the hepatoduodenal ligament - caused the conversion to open surgery in one (2.6%) case in chronic calculous cholecystitis.
III. Complications arising during surgery, winch were not possible to manage using the laparoscopic technique.
1. Bleeding (a total of 12 cases):
a. From the cystic artery. According to different authors, it occurs in 1.7-3.5% of cases, and the need to convert to laparotomy appears in 0.33-1.6% of cases. According to our data, this complication has led to the conversion of two (4.4%) patients with acute calculous cholecystitis and 2 (5.3%) with chronic calculous cholecystitis.
b. From the gallbladder bed, (bleeding from the liver parenchyma and major damage to the hepatic veins that run close to the surface in the bed). In acute calculous cholecystitis - 2 (4.4%) observations, in chronic calculous cholecystitis - 3 (7.9%).
c. From the hepatic arteries (right or left). There was one damage to the left hepatic artery in chronic calculous cholecystitis with the involvement of the hepatoduodenal ligament with massive bleeding that led to death on the operating table. The source of bleeding was found only during autopsy.
d. Bleeding from a vein in the gallbladder wall, against the background of portal hypertension and accompanied by massive blood loss caused conversion in one case.
e. Bleeding from injured hepatic hemangioma during surgery - 1.
f. Bleeding from the common hepatic artery.
g. From the retroperitoneal vessels (aorta, inferior vena cava).
h. From the portal vein.
Ø The last three options were not encountered in this observation. The only vascular formation, structure and topography that is always stable is the portal vein. However, its damage during laparoscopic cholecystitis is possible; it is usually the most dangerous and often leads to death on the operating table. This can happen only due to the erroneous mobilization of the hepaticocholedochus when it is mistaken for the cystic duct.
2. Bile duct injury that required conversion in acute calculous cholecystitis was diagnosed in one case, in chronic calculous cholecystitis - 2. It should be noted that laparoscopic correction of the damage to the common bile duct was performed using endocorporal suturing.
3. Damage to a hollow organ that cannot be corrected laparoscopically. Damage to hollow organs diagnosed intraoperatively during laparoscopic cholecystectomy was not observed in our hospital.
4. Lost stones. In one observation, a large stone was lost during laparoscopic cholecystectomy, which could not be found laparoscopically. During laparotomy, after a long search, it was found in the omental bursa, where it got through the Winslow (epiploic) foramen.
IV. Technical problems in the equipment that might occur during the intervention that cannot be repaired immediately, irrational choice of operational positions, the type of optics, tools, and modes of electrocoagulation.
Table 2. Reasons for conversion in acute calculous cholecystitis
Reason
|
# of observations
|
%
|
|
Dense infiltrate in the area of the gallbladder
|
24
|
53.4%
|
|
Pericholecystic abscess
|
9
|
20%
|
|
Cancer of the gallbladder
|
2
|
4.4%
|
|
Gangrene of the wall of the gallbladder
|
2
|
4.4%
|
|
Cholecystogastric fistula
|
2
|
4.4%
|
|
Stricture of vater papilla, cholangitis.
|
1
|
2.2%
|
|
Bleeding from cystic artery
|
2
|
4.4%
|
|
Bleeding from gallbladder bed.
|
2
|
4.4%
|
|
Damage to the choledochus
|
1
|
2.2%
|
|
Total
|
45
|
||
Table 3. Reasons for conversion in chronic cholecystitis
|
|||
Reason
|
# of
Observations
|
%
|
|
Dense infiltrate in the area of the gallbladder
|
10
|
26.3%
|
|
Mirizzi symdrome
|
2
|
5.3%
|
|
Adhesive process around the gallbladder
|
5
|
13.2%
|
|
Adhesive process in the abdominal cavity.
|
2
|
5.3%
|
|
Sclerotic gallbladder
|
2
|
5.3%
|
|
Choledocholithiasis
|
4
|
10.5%
|
|
Choledochoduodenal fistula
|
1
|
2.6%
|
|
Obscure anatomical relationships at the region of the neck of GB
|
1
|
2.6%
|
|
Bleeding from the cystic artery
|
2
|
5.3%
|
|
Bleeding from the gallbladder bed
|
3
|
7.9%
|
|
Bleeding from the left hepatic artery
|
1
|
2.6%
|
|
Bleeding from a vein in the gallbladder wall
|
1
|
2.6%
|
|
Bleeding from hepatic hemangioma
|
1
|
2.6%
|
|
Injury to the choledochus
|
2
|
5.3%
|
|
Lost stones
|
1
|
2.6%
|
|
Total
|
38
|
||
As our resident surgeons gain experience of laparoscopic surgery and improve operating technique, the percentage of conversions gradually decreases. In 2013, the total number of laparoscopic surgery for acute calculous cholecystitis amounted to 15.6% of all laparoscopic cholecystectomies, in 2014 - 32%, and in 2015 - 47.7%. Total number of laparoscopically operated patients with acute calculous cholecystitis is about 78%. Given the complexity of the operated pathology and the increase in the number of surgeons that master the laparoscopic method of operation, the total number of conversions is stagnant. To date, laparoscopic surgery is performed by 90% of the general surgeons in the surgical department of our hospital.
Reasons for anatomical disorientation in laparoscopic cholecystectomy.
Due to the nature of the technology, surgeons do not immediately go on intersecting organs, but approach them slowly by dividing the tissue covering them in small portions. However, even minor bleeding from small blood vessels impairs visualization of the layers, walls of the gallbladder, vascular and ductal structures, which is one of the most frequent causes of disorientation of the Surgeon in anatomical proportions. Conditions such as excessive fat deposition, infiltrative processes and fibrosis, acute inflammation accompanied by increased tissue bleeding, making it difficult to differentiate boundaries and contours of anatomical elements degrade the outcome of the operation. Under these conditions, seeing only a part of the organ, the surgeon must constantly think of the ratio of limited surgical field area with a common position of all other organs and anatomical elements of the gallbladder, its form, location of the duct, vessels and the hepatoduodenal ligament involved in the operation.
In addition to these features of laparoscopic cholecystectomy, the other major cause of anatomical disorientation of the surgeon and possible severe complications are atypical forms of anatomical variants of the gallbladder, the cystic duct, the location and the branch of the cystic and right hepatic arteries, as well as general patterns and individual variants of transformation of these formations during inflammation.
The most dangerous situation is with a short cystic duct, because, as often observed in practice insufficient mobilization of the gallbladder wall in the neck and vesico-ductal region, a short cystic duct can be masked or hidden in fat deposits and can be mistaken as the common bile duct. This is a common and very typical mistake. In inflammatory conditions, the danger increases dramatically. In the inflammatory infiltrate, the cystic duct approaches the hepaticocholedochus and along with the neck of the gallbladder, it is always shifted in the dense inflammatory tissues up toward the porta hepatis.
Regardless of the variants of the structure of the cystic duct as an extremely dangerous situation, the initially close adjacency of the common hepatic duct and right lobar duct to the rear wall of the gallbladder should also be considered. Due to inflammation, this adjacency is transformed into an intimate, dense fusion of the bile ducts and gallbladder that can lead to serious injuries to the ducts.
Conversion to laparotomy during laparoscopic appendectomy
With relatively little experience in laparoscopic appendectomy - 27 operations, which was started in 2013 by our resident surgeons, however, we encountered a number of difficulties that caused the conversion in 25.9% of cases. There were no complications observed during laparoscopic appendectomy and in the postoperative period.
Table 4.
Reasons for conversion
|
№ of observations
|
%
|
Appendicular infiltrate
|
3
|
42.8%
|
Retrocecal position of the appendix
|
1
|
14.3%
|
Gangrene with perforation of the appendix
|
1
|
14.3%
|
Impossibility to define the source of peritonitis
|
1
|
14.3%
|
Adhesive process around the appendix
|
1
|
14.3%
|
Total
|
7
|
Conversion to laparotomy during laparoscopic surgery for acute pancreatitis.
Laparoscopic technology in the surgery of acute pancreatitis was introduced in our study in 2014. In this sequence, we pursued three objectives: a) confirmation of the diagnosis of acute pancreatitis and presence of effusion in the free abdominal cavity; b) laparoscopic drainage of paracolic gutters and pelvis; c) inspection and laparoscopic drainage of omental bursa. The reasons for the conversions were:
Table 5.
Reasons for conversion
|
№ of conversions
|
Adhesive process in the abdominal cavity
|
2
|
Impossibility to define source of peritonitis
|
1
|
Infiltrate around the gastro-colic ligament
|
2
|
Bleeding from the vessels of the gastro-colic ligament
|
1
|
Total
|
6
|
Conversion to laparotomy during laparoscopic surgery for adhesive disease and adhesive intestinal obstruction.
Laparoscopic surgery for abdominal adhesive disease as an independent disease, rather than comorbidity, has been carried out in our hospital for quite some time now. The diagnosis is verified based on history, clinical symptoms, enterography, lower gastrointestinal series (barium enema) and ultrasound examinations of the abdomen. Laparoscopic adhesiolysis was performed by our resident surgeons in adhesive small bowel obstruction. In all the 26 operations performed, there were four (15.4%) conversions.
Table 6.
Reasons for conversion
|
№ of conversions
|
Adhesive process in the abdominal cavity
|
1
|
Injury to small intestine
|
1
|
Dense conglomerate of the loops of the small intestine
|
1
|
Tight fusion with anterior abdominal wall
|
1
|
Total
|
4
|
Surgical treatment of adhesive disease using laparoscopic method is more efficient because of less intraoperative tissue trauma, and is therefore associated with fewer recurrences and today it is the operation of choice in this pathology. In our opinion, adhesiolysis is most effective in the presence of individual adhesions. Preference must only be given to the traditional way of operation when the risk of laparoscopic adhesiolysis exceeds the risk of negative consequences of laparotomy.
Conclusion:
With the improvement of operating skills, development of new technological solutions, steadfastness and hard work of our surgeons, the emergence of new equipment and tools, improved anesthetic technique there is a reduction in the number of situations that were previously not allowing to complete the operation laparoscopically or a contraindication to this kind of intervention.
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